Author: LfE

In the middle of September, on a warm late summer’s evening in Staffordshire, a gathering of people came to find out a little more about LfE. Sponsored by the WMAHSN, this was also a chance to share – experiences, knowledge, successes as well as concerns – about starting or developing projects which facilitate the communication of appreciation of the ‘everyday excellence’ of frontline healthcare work. Whilst this is a determinedly positive approach, it is conducted in the knowledge that there are necessary constraints when working within healthcare organisations. Risk and uncertainty are ever-present reminders that ‘things could go wrong’. But the ‘reality’ is that healthcare professionals don’t enter into this demanding work intending for such ‘things’ to happen.

Management of risk takes many forms, but one approach that remains high profile in any risk-laden sector is standardisation. This usually takes the form of the standardisation of operational procedures using protocols and pathways. Influenced by sectors characterised by high reliability organisations, healthcare has caught the standardisation ‘bug’.

The reason for mentioning this? Rather than drifting off topic, it is actually central to my purpose. At the LfE event in Stoke, standardisation was raised as key to patient safety efforts. A questioner legitimately wondered out loud whether projects like LfE might be missing the point of the importance of something as significant as standardisation. Surely, the standardisation of ‘good practice’ just means the same thing as that work proposed by LfE? Part of Dr Adrian Plunkett’s response was that whilst there was a truth to this, the standardisation of appreciation for excellent work – that is, perhaps, of good practice under conditions of stress and strain in the system – might just be one of the things missing from healthcare. And therefore, by extension, that this adds something to patient safety that is not accounted for by the standardisation project.

Nearly a decade ago the World Health Organisation (WHO) set out the ‘High 5s’ – five key areas within healthcare identified as significant weak-points in relation to patient safety deemed likely to benefit from standardisation. The areas included hand hygiene, medication and surgical management, as well as clinical handover communication. In a recent review of movement towards globally-applicable Standard Operating Protocols (SOPs), Agnes Leotsakos and her colleagues reported upon some of the successes and the challenges which have emerged. Inevitably, concessions have had to be made (e.g. not all of the five areas of work were amenable to SOPs) and the final report isn’t yet available (it’s due imminently, in late 2016). However, even though the work was commenced in 2007, they claim this approach to quality and safety in healthcare is still in its early stages. This isn’t disappointing; rather, it’s realistic and seems to align with the experience of planning, delivering and evaluating frontline healthcare in the face of patient safety concerns. It takes time, but those involved believe it can be done.

Patient safety is itself a complex endeavour. Interest is beginning to be directed more systematically towards the emotional element of patient safety work. Heyhoe and her colleagues have recently offered a clear framework for understanding at least some of these elements. In taking a balanced perspective, they include both ends of the valence spectrum i.e. positive as well as negative emotions. Emotion, they suggest, can impact upon decision-making, patient outcomes as well as how clinicians approach and understand their work. The broader literature and evidence-base is building to give even more support to this take on healthcare.

And so, rather than seeing the work of initiatives such as LfE as being in some way a deviation or distraction from the agenda which is driving towards standardisation, there is another view. Recognising, supporting and appreciating the excellence evident in the everyday work of healthcare professionals can contribute towards positive emotions in and around that vital work. And this then augments and supports ‘good’ processes in patient safety work. It may even contribute towards the unlocking of a deeper understanding of the obstacles still being faced in attempting to introduce and implement standardisation in healthcare. As Leotsakos herself states, SOPs are a part of the process which itself recognises and advances excellence in healthcare practice.

LfE and standardisation aren’t then, if you are open to considering this perspective, in any way in opposition. They aren’t even just working (separately) towards the same goal. They are mutual and interdependent. Adrian was – and is – onto something ‘big’ here!

I recently listened to this excellent podcast from radio 4: The Blame Game – 03/05/2016. I heard about various industries in which a blame culture is prevalent: health (midwifery), MI5, sports, politics and others. By the end I came to the conclusion that blame is never useful. It is not the same as accountability; blame is a cop out. It is fuelled by fear and an attempt to protect our own egos. A culture of blame will stifle innovation, promote self protection and lead to defensive behaviour driven by fear of reprimand and litigation.

A proposed solution is to create a ‘just’ culture: a culture where we acknowledge mistakes and learn from them, without apportioning blame. This sounds like a good idea in principle, but practical solutions to help us make the cultural switch are lacking. Also, I can’t help feeling that we can do better. It just seems a bit flat; somewhat one dimensional. Where’s the inspiration? It feels like we’re heading for mediocrity, by trying to avoid things going badly. Can’t we try to create something inspiring: a culture where excellence is given its own status? Can we not shoot for the moon? If ‘blame culture’ is downright wrong, ‘just culture’ is safe and mediocre. I would like to see a nurturing culture where excellence is routinely highlighted and appreciated; where staff are motivated and their work is regularly celebrated; where colleagues support each other; where bullying is expelled and blue-sky thinking and dreaming about a good future is part of daily practice.

It might sound a bit far-fetched, but some days I think we’re almost there.

We have produced a quick start-up guide for organisations interested in launching their own version of Learning from Excellence. The document is now available on our resources page. Printed versions will be available at our Learning from Excellence event tonight – 19th July 2016: “where did it all go so right?”

The following guest blog post is from Dr Clarissa Chase , an ST5 trainee in paediatrics, at Southampton General Hospital. Clarissa conceived a positive reporting system called “FERF”. The story of FERF is below:

It seems almost every day that a negative healthcare story makes its way into the headlines; missed diagnoses; missed opportunities; repeated failings that suggest a lack of learning from previous serious incidents.

While the issues raised by these stories may be significant, the articles rarely present a balanced account. The distorted information is presented for maximum impact and consequently effects public perception of us all.

As healthcare professionals, we have no right to reply or publicly defend these cases. As we are in the business of preventing harm and striving for clinical excellence it is difficult to know how to manage such misrepresentation. Not least because the barrage of negative press stories and distorted perceptions of NHS care must be having a negative effect on the morale of our workforce.

I don’t think anyone would deny that learning from mistakes is essential.

Reviewing failings, whether in the form of a formal inquiry or simply personal reflection, is necessary to identify hazards or risks and target improvements to address these and prevent any recurrence. Patient safety is paramount and we have a myriad processes to direct our focus at this; adverse incident reporting forms; patient complaint processes; the National Reporting and Learning System to name but a few. All these processes have been designed around identifying adverse events. Perhaps we are guilty ourselves of propagating this endless focus on the negatives, thus further perpetuating dwindling morale.

A 2007 survey for Hospital Doctor suggested 69% of doctors in the UK reported falling morale. The reasons for this are likely to be complex and varied, but might at least in part be a result of a relentless attention on adversity, both within the NHS and in the wider public forum.

So what if we turned that on its head? Redress the balance and recognise that it is as important to learn from the things that go well; the good things we all do every day that get little or no recognition: instead of learning from an example of incorrect care of a post-operative patient resulting from poor handover of information on arrival to the ward, identify the cases where the handover is exemplary and evaluate what makes it so, in order to encourage the process to happen in this way each time. Identify the details of specific positive examples, use them to educate and we will all learn from good practice.

Positive reinforcement is a well-recognised concept first described by psychologist BF Skinner that describes the reinforcement of a specific desired behaviour using a reward; a positive event that follows a particular action will reinforce it and make it more likely to happen again.

Putting this into context within the NHS would seem simple: if the reinforcement takes the form of specific positive feedback, for example: ‘I think you managed that consultation well – you involved the patient in the decision making and summarised all the information clearly’ then we will start to recognise all the things that we all do well every day, while we emphasise what works well and, in so doing, ensure continued good practice. The side effect of this process might be to increase morale and confidence. It will change the way people think about one another and build a stronger team.

I remember an incident as a junior registrar in 2012 when one of my consultants was admitting someone unexpectedly to the ward after clinic. As I was the registrar covering the evening shift she came and found me and took me to the clinic room to meet the parents and their baby. While we were in the clinic room she explained the reason for admission to me, in front of the parents and explained her proposed plan for overnight. I was then able to accompany the parents to the ward and introduce them to the ward staff. It struck me that her actions had a big impact on the very anxious parents. They clearly felt reassured that the discussions had both happened in their presence, and involving them.

Two other things struck me that day: 1) did my consultant realise the positive impact of her actions and 2) what a shame that I was the only person around to learn from her brilliant practice. I wanted to find a way to recognise, emphasise and learn from positive events.

And so the idea of Favourable Event Reporting Forms (FERF) was born. The concept was simple: a paper reporting form to identify positive practice and the individuals involved that could be filled in by any member of the team. A multidisciplinary team would then review the forms monthly and the learning points for each of the events drawn out. These learning points would then provide feedback both to the individuals involved, and to the rest of the team. The individual would receive a letter from the clinical leads of the team. The event and learning point would also be summarised and displayed on a noticeboard for staff, patients and visitors to see, as well as being discussed in Mortality and Morbidity meetings and education sessions.

The FERF initiative has been extremely well received in many different clinical areas. As well as enabling learning from positive practice, FERF provides a mechanism for individual professional development and has increased morale among all members of the multidisciplinary team. In addition to being used by patients and relatives and for patients and relatives, many have commented on how pleased and reassured they are to see both examples of positive practice and learning from positive practice.

While striving for clinical excellence we should recognise and celebrate our successes, learn from one other and from the hundreds of brilliant things we all do every day. If we change the way we value each other perhaps we will change the way others view us too.

In the transfer window of 2011 I found myself with the quite unexpected opportunity of joining the team at University Hospitals of Coventry and Warwickshire. This was both exciting and simultaneously daunting; exciting because UHCW was in the process of becoming one of the 3 West Midlands adult Major Trauma Centres, daunting because it came with a reputation for excellence which I wasn’t at all sure I could live up to. As the starting date approached I became a little more anxious. Surely they wouldn’t be all that good? After all we had all had similar training and all had the same post graduate exams and life support courses.

Anyhow, the day came when I started. I settled down into the miasma of new systems and became lost in the process of learning a new job. That is, until the trauma call went out. Fortunately, I was not running the call and as such was able to watch. I settled against the back wall, happy that my lack of height would be a further defense to exposing myself as a charlatan in resus, whilst secretly hoping that I might recognise the process and feel that it was not out of reach.

What I saw was far worse than I had imagined.

Gary Ward walked in, took control of his team, ensured everyone knew their role, was happy with it and felt able to contribute. He then delivered text-book trauma leadership, creating, at its core, a small oasis of calm in the otherwise frenetic environment of a busy resus. Dialogue flowed back and forth, team members were addressed by name and there was consistent clarity of purpose. The patient had their primary survey and initial workup in less than 10 minutes, making it into the CT scanner in less than 12. I was horrified, this wasn’t just good- this was outstanding.

I decided that I would watch a few more traumas being run; after all, Gary came with a reputation for excellence and perhaps I could find someone with a more realistic level to aspire to. The next person I watched was Caroline Leech. Once more I stood in the background and watched as, in a slightly different style, another masterclass in initial trauma management was delivered. Over the next few days and weeks I watched as Rob Simpson, Louise Woolrich-Burt, Jim Davidson and others each brought their own style to the basics of ATLS/ETC to create what felt like amazing teams from groups of disparate individuals. They did this rapidly, succinctly and in a way that allowed the whole team to feel valued. The sense of being out of my league only grew.

At some point, I realised that there were things that each was doing that appeared to help the team to come together. From discussing with the trauma team leaders however, it was also clear that they were not quite sure how they did it “It’s just my style” and “I just do it how I do it” being amongst the replies I received when I asked about this.

Just asking the leaders wasn’t going to get the answers I was looking for. So, working alongside Dr Amy Randle (then an ACCS trainee), we developed an anonymised qualitative questionnaire that was distributed to members of the multi-disciplinary trauma teams. We asked what they liked, what they didn’t like and whom they thought was the best trauma team leader. We received over 100 replies and they are summarised below.

Positive attributes:

Negative attributes:

It may seem odd, but seeing this written down has been a great help. It has provided a structure to consider our behaviours and to think about the atmosphere we create in real time. But we did much more with this- we used it to form part of our peer review process and have had collective discussions so that everyone can learn from each other. By describing both the good and the bad we have given clarity to the behaviours that encourage and inhibit excellence.

The following guest blog is from Mike Clift. Mike spoke at our meeting in January 2016, on the topic of Compassionate Healthcare.

I was asked to write this blog shortly after presenting my compassionate healthcare work at the Learning from Excellence workshop event in late January. Nearly four months later, I’m finally doing it. I’m as prone to procrastination as anyone but this time some significant life events genuinely got in the way of writing this, and those events have given me more reason than usual to reflect on the journey I’ve been on with this work and where I am now.

At the time of the workshop I was just finishing-off an MSC and three months into a new job where I was directly managing a team for the first time. Two months later a young relative died after a two-year struggle with cancer. Shortly after that, my relationship broke down. Before you stop reading – don’t worry! I’m fine and there is a point to these perhaps uncomfortable disclosures. For a long time I was living with things in my life that are no longer there, which has cumulatively given me more head and heart space overall, but rapidly put me in a fairly unexpected place of reflection rather than fairly constant action. I’ve had big emotional investments come to a form of close while I’ve had to maintain my levels of focus and emotional engagement in a newly formed role managing a newly formed and growing team who need my guidance and strength if I’m to do this new job well. As with anything, I can’t claim to have done that perfectly, but without some of the skills I’ve partly learnt as a result of the professional journey I’ve been on with compassionate healthcare, I may have done it much more poorly.

When I present I often stress that to maintain and develop your compassion you need improved self-management of your thoughts and emotions. Mindfulness is a core skill in many approaches developed to do this, such as compassionate-mind training and acceptance and commitment training; and over this challenging period I drew on my growing skill in being able to draw my wandering, distracted mind and heart back to the present moment and the person in front of me, whether a member of staff, a patient or anyone outside work too. My final MSC module was an assessment of the impact of a conference on compassionate healthcare I led on in March 2015. My conclusion was that inspired and enthusiastic staff then need ongoing opportunities to learn further and practice the skills that were highlighted, including mindfulness. I created a big bang but only sketchy plans for the ongoing evolution. I was lucky. I coincidentally learnt meditation and mindfulness a year or so before my compassion journey started and have practiced them ever since, which has become another welcome piece of synchronicity between my personal and professional life.

My real challenge now is having learnt how to successfully engage an organisation with this work, I now need to work towards providing staff and students with accessible, ongoing opportunities to learn the skills which I’ve benefited from and have made me a more resilient human being. Whatever life throws at us as healthcare workers, we still need enough heart to offer our patients and the staff that need our support and guidance but some of us, like myself, need to learn how to do it better first and healthcare organisations and the leaders and managers within them can do more to provide those learning opportunities.

This morning I opened my email inbox to find two unread excellence reports. The first was from a consultant surgeon. He had reported excellence in his theatre staff for staying late to finish some cases. The patients had benefited from this sacrifice and the consultant surgeon wanted to say thank you. He could have gone to each individual and said thank you directly – perhaps he did – but he chose to make it more formal by reporting this through our excellence reporting system. The second report was from a nurse who had cited the Chief Executive Officer of the trust for excellence in dealing with a particular issue in her department.

Both of these reports were essentially a formal notification of thanks. At first glance neither of these reports contain much ‘actionable intelligence’. These are just thank you letters between members of staff. All very nice, but where’s the learning?

The key to these reports is their sincerity. The excellence reports require free text entry, so the reports are written in the words of the author. There is no forced categorisation; no drop-down menus. Just free writing. This allows the sincerity to shine through. The reports are delivered verbatim to the reported staff member. So the theatre staff and the CEO will soon be receiving the same copy of the reports I read this morning. What will their reactions be? How will they feel?

My bet is that they will feel appreciated. Appreciation is different from reward. Appreciation is being positively noticed (or not being ignored, depending on your perspective). This taps into intrinsic motivation and makes us more likely to want to repeat our actions. Reward, in contrast, is an extrinsic motivator; a carrot, from the stick and carrot concept. Reward works to a point, but ultimately we tire of these motivators. Reward and punishment are management concepts from the industrial age, and they are now outdated.

Don Berwick recently wrote an opinion piece about eras in healthcare. http://jama.jamanetwork.com/mobile/article.aspx?articleid=2499845 He proposes that there have been two historical eras in healthcare: era 1, characterised by professional trust and prerogative; and era 2, characterised by accountability, scrutiny, measurement, incentives, and markets. He suggests that it is time for era 3: a moral era. The article contains nine suggested changes to move to the next era, one of which is to protect civility. Berwick writes, “Medicine should not…substitute accusation for conversation”. Whilst this may seem obvious, the truth is that it is often forgotten in reality. Under pressure, civility is often one of the first things to buckle.

How can we protect civility? A starting point would be to encourage a culture of appreciation for our colleagues. “Thank you” and “well done” are usually followed by positive dialogue which can form a strong foundation for learning how to improve. Indeed, the recognition of good practice is likely to increase the prevalence of further good practice. It may well be the simplest quality improvement intervention there is.

On 22nd January I was privileged to attend the first national Learning from Excellence event hosted by Dr Adrian Plunkett at Birmingham Childrens’ Hospital. As a former West Midlands paediatric trainee who has rotated through BCH PICU twice I was aware of the fantastic work Adrian and the team had undertaken and had witnessed first hand the positive effects this had on staff. On joining the Paediatric Emergency Medicine team at Leicester Royal Infirmary I was keen in some way to introduce the learning from excellence philosophy. This idea complimented the Critically Careful Forum which Dr Gareth Lewis was already running in the department.

It was the story of our journey and experiences with the Critically Careful Forum, the good and bad, ups and downs that I was able to share with the audience on the 22nd. I am aware that running a regular ‘Awesome and Amazing’ style meeting in an emergency department for many will be common practice. Unfortunately there was nothing being delivered locally to provide multidisciplinary education for our staff. Originally this monthly meeting was slow to get off the ground however it has gone from strength to strength. This is a little scary as there is a definite expectation now from the staff who for the majority attend in their own time.

Ultimately we reflect on what has always been a busy previous month in the department. We highlight a selection of cases which traditionally have been some of the more difficult and challenging ones with relevant learning points. We have noted that there have been struggles to fully adopt a learning from excellence approach due to the self-deprecating nature of many of our staff. Even those working in a paediatric emergency department struggle with the concept that not every child gets better. There is often a feeling of, “what did we do wrong?” or “what could we do better?” when the answer is “nothing!”

We are increasingly however pushing ahead with learning from excellence as it is these cases that we believe we have most to learn from. In the past 6 weeks we have introduced a new sepsis bundle and last month saw evidence of its success. A patient with severe sepsis was identified at triage, prioritised for senior medical review and transferred to resus where ultimately care progressed to PICU level support with intubation, ventilation, antibiotics, fluid boluses and inotropes within 35 minutes of the child arriving. This care will be highlighted and discussed at length but we will also recognise the wider staff efforts; those that ‘stepped-up’ to maintain excellent care for the other children in the department.

In this way I feel we have been able to maintain staff morale at high levels during a busy and challenging winter period. I believe that this is an under-recognised benefit of the learning from excellence process.

I hope I was able to inspire some in the audience with our experience from Leicester, certainly I came away invigorated with lots of great ideas I am already setting into motion to allow us to better recognise and highlight the great work in our immediate and wider team.

I’ve been a doctor for 22 weeks now, and it sure has been a steep learning curve! But, you know what I’ve noticed most, during my short NHS employment, I’ve noticed that healthcare professionals go the extra mile. Day in, day out. Excellent practice happens all the time. Perhaps we take this excellence for granted, because it appears to me that it often goes unremarked. Of course, we should always be striving for excellence, and excellence should be happening daily in order to provide the best care we can for our patients. However, healthcare systems do not seem to acknowledge excellence, instead there is a focus on error, blame and mistakes. Being told off all the time is not good for anyone. It just does not motivate. So is measuring error the only way we can improve healthcare? Or, can we drive better care by measuring excellence too?

We wanted to test this idea, that excellence can help medicine improve, with a quantitative study. We looked at the drug chart documentation of antimicrobials against an audit standard in a Paediatric Intensive Care Unit (PICU). An antimicrobial prescription which met all 11 audit standards was deemed a ‘gold standard’ prescription. We determined the prevalence of gold standard prescriptions both before and after a few weeks of ‘intervention’: positive reporting via the IR2 forms. These IR2 forms are a source of positive feedback which describe excellent clinical practice. The IR2 can be filled in by anyone and are passed on to the individual via the clinical governance team, creating a positive feedback environment.

In this study the IR2 forms were used as an intervention to detail the prescriber’s gold standard documentation – their clinical excellence. After this intervention we found that there was a significant increase in the number of gold standard prescriptions on PICU. This demonstrates that positive reporting can have an impact on clinical practice and could improve patient safety.

The following guest blog is from Dr Elspeth McAdam, Retired Consultant Child and Family Psychiatrist & Organisational Coach. Elspeth’s blog is a reflection on her experiences of using Appreciative Inquiry in healthcare.

The old English adage – “You learn by your mistakes” has been a travesty to humanity. The more you go over what you did wrong, the more you become an expert in how to do the wrong thing! Each time you repeat the action/activity you automatically go through what your “body“ knows and you have to stop and think about what not to do. By closely examining excellent practice, on the other hand, you are looking at what has worked brilliantly, so subsequently you may act in the same way. In-depth questioning about what made it work so well can help others understand how to repeat it. Whilst going through these details of the excellent practice, the skills and abilities used should be identified, named and given to the person who accomplished it. Once these skills are named and accepted by the person who performed them, they then become a resource to that person, as well as a learning item for the observers.

The other valuable resource that comes from Appreciative Inquiry is to DREAM. REMEMBER EVERY PROBLEM IS A FRUSTRATED DREAM. If you did not have dreams of good practice you would have no problems! So instead of dissecting the problem, have a dream about how you would like it to have gone. Remember to dream as if you are living it at that moment, so speak in the present tense.

For example:

Let’s dream, with all the staff present, about what an excellent ward round looks like. What is each of us doing; how did we prepare for it; how are we talking to the patients; how we teaching? What explanations are we giving the patients/staff/students etc? Talk as if you are doing it in the now. If you are working with a larger group, divide the group into smaller groups of 6, so everyone has a chance to speak their ideas. Dream what an ideal hand-over and ward-round looks like. Imagine it is now 2018, and all the current problems are solved. What are we doing so well now? When we follow this process, the past difficulties become part of the process of creating the dream. This gives us new ideas from “the frustrated dream” to inform our “future-present”. E.g. we learnt a lot from that, now we do it this way… The more detailed the dream the more likely it is to be lived in the future.